Clinical Document Integrity Specialist - RN (PRN)

Clinical Document Integrity Specialist - RN (PRN) The CDI Specialist facilitates appropriate clinical documentation reviews concurrently to ensure that the level and acuity of services are accurately reflected in the medical record to improve overall quality and completeness of clinical documentation. They communicate effectively with physicians and the healthcare team, initiate provider queries as appropriate for documentation clarification and specificity. Benefits PPO medical plan, available day one at no cost for full‑time employee‑only coverage 100% coverage for preventive healthcare – no copay Paid Time Off, available day one Retirement Programs through the Teacher Retirement System of Texas (TRS) Paid Parental Leave Benefit Wellness programs Tuition Reimbursement Public Service Loan Forgiveness (PSLF) Qualified Employer Experience and Education Required Education – Bachelor’s Degree in Nursing, BSN Experience – 3 years acute care hospital nursing experience, preferably in critical care (e.g. ED, Trauma, Critical Care Units) and 2 years experience working in a Clinical Documentation Integrity program, or 5 years acute care nursing experience including 3 years in critical care. Licenses and Certifications – RN, upon hire; CCDS, obtained within 6 months; CDIP, obtained within 6 months. Preferred – Experience working in a remote environment. Job Duties Facilitate appropriate clinical documentation to ensure that level of services and acuity of care are accurately reflected for quality and completeness. Communicate effectively with physicians, the healthcare team and multidisciplinary teams to ensure accurate documentation of diagnoses, procedures and treatments; provide education on documentation opportunities. Initiate physician queries for clarification and specificity following established guidelines; perform follow‑ups to ensure documentation prior to discharge. Perform follow‑up reviews and update CDI/DRG worksheet to reflect changes in patient status, verifying appropriate primary diagnosis and DRG and validating supporting documentation. Collaborate with Coding and Quality teams to bridge gaps between clinical and coding language. Maintain expert knowledge of CDI practice and performance. Provide backup for other CDI Specialists as needed. Support Quality Standards set by UTSW and the HIM Coding & CDI Department. Other duties as assigned. Security This position is security‑sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information. EEO Statement UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination, including discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status. #J-18808-Ljbffr The University of Texas Southwestern Medical Center